Practical insight into upright breech birth from birth videos: A structured analysis

Abstract

Background: We aimed to identify common features of upright vaginal breech births with good outcomes to refine a physiological approach to teaching breech birth.

Methods: We performed a structured analysis of 42 videos of successful upright breech births (eg, kneeling, hand/knees), facilitated by obstetricians (n = 34) and midwives (n = 8) in nine different countries. Precise timings and relevant clinical details were recorded on an Excel spreadsheet. Each video was analyzed twice by at least two members of the research team. Time-to-event intervals, frequencies of interventions, and descriptive statistics were calculated using SPSS.

Results: A completely spontaneous (labor mechanisms and maternal effort only) birth occurred in 14/42 (33%) cases. The median time between the birth of the fetal pelvis and the head in all births was 1:52 (IQR 1:05,2:46; min:sec). Lack of spontaneous rotation to a sacro-anterior position by the time the fetus had emerged to the nipple line was strongly associated with fetal arm entrapment. The following maneuvers were used: shoulder press to flex the aftercoming head in midpelvis or outlet (n = 24), sweeping down arm/s (n = 12), buttock lift to assist shoulder press (n = 6), modified Mauriceau (n = 6), rotational maneuvers to release an entrapped arm (n = 6), elevate and rotate fetal head to assist engagement (n = 2), and conversion into supine maternal position (n = 2).

Conclusions: Most upright breech births occur within 3 minutes of the birth of the fetal pelvis. Upright breech birth attendants use variations of traditional maneuvers. We introduce a physiological breech algorithm as an initial timekeeping framework for teaching, research, and practice.

Keywords: algorithm; birth videos; breech presentation; intrapartum care; mechanisms.

Figure 1

Variations of sacral rotation at the nipple line. From left to right: (1) complete sacro‐anterior rotation; (2) partial sacro‐anterior rotation into oblique; (3) no rotation, sacro‐transverse. Image credits: Shawn Walker, Anke Reitter, Emiliano Chavira

Figure 2

Physiological Breech Birth Algorithm. Designed by Shawn Walker, RM PhD, version: Nov 2019

Figure 3

Assisting the birth of the head in physiological breech births. Head at the pelvic inlet: Elevate and rotate (top): (1) The birth attendant runs a finger up to identify that the chin is high; the head is extended and trapped at the inlet to the pelvis. (2) Using “flat hands” (also called “prayer hands”), the birth attendant shifts one hand onto the chest of the newborn. Another hand, on the back of the newborn, shifts up to elevate and lift the occiput off the maternal pubic bone. If necessary, the occiput would be rotated at this point into oblique or transverse to assist engagement. (3) Once engaged in the pelvis, the neonatal head is flexed and realigned in the pelvis. The head is then delivered by a shoulder press or variation of Mauriceau. Head in the midpelvis or outlet : Shoulder press (bottom) flexes the fetal head by moving the newborn's shoulder girdle and body toward the maternal abdomen, much like supine maneuvers to deliver the head. The pubic bone becomes a fulcrum, which lifts the occiput as the head pivots around the maternal sacral curve. This is performed either by pressing on the fetal chest, just below the clavicle, or with thumbs on the fetal chest and fingers wrapped around the shoulders. Buttock lift augments the effectiveness of shoulder press by slightly elevating the maternal sacrum, enlarging the anterior‐posterior diameter of the pelvic outlet, and sweeping the perineum over the newborn's forehead. Scoop and flex can be used if the above are not successful, or to align the head in the pelvis. The birth attendant sweeps one hand over the parietal bone and flexes the head down by pressing on the sinciput (forehead). Drawings by Merlin Strangeway, Drawn to Medicine